Complete Risk Review

Your risks, covered

A GREAT OPPORTUNITY TO ASSESS COVERAGE.

There’s one guarantee in life and business. Things change. Our annual review is an opportunity to compare your existing coverage against your current needs to ensure your insurance remains appropriate to your situation.

Here to Help

Complete Annual Review

Step 1 of 9

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The purpose of this questionnaire is to gather background on risks commonly experienced by families and businesses; it is not inclusive of all risks nor does your insurance agent necessarily offer insurance for all listed risks. Coverage will not be bound by completing this questionnaire, and your specific coverage needs must be discussed with your agent prior to obtaining a policy.

Client Information

Primary Contact Name*

FirstLast

What type(s) of insurance do you currently have with us?*

Personal Insurance

Business Insurance

Home Address*

Street AddressAddress Line 2CityStateZIP Code

Make and Model of Vehicles*

Make/Model

Year

Primary Driver

Company Name*

Company Address*

Street AddressAddress Line 2CityStateZIP Code

Total Annual Sales*

Total Number of Employees*

Phone Number

Email Address*

Your Home

Please think back over the last year when answering these questions.

Are any members of your household not related to you?*

Yes

No

(New roof, furnace, or electrical system)

Do you have any children who are full-time college students?*

Yes

No

Are any of your family members living in an assisted-living care facility?*

Yes

No

Do you own any other real estate such as a vacation residence or farm land?*

Yes

No

Do you own any property which you rent to someone else?*

Yes

No

Do you own any structures that are not residences that are located away from your residence premises?*

Yes

No

Do you live in a condo or development in which you are assessed for the maintenance of the property?*

Yes

No

Do you regularly conduct any business activities from your residence?*

Yes

No

Do you store any type of business property on or around your residence?*

Yes

No

Do you baby-sit or operate a child daycare in your home?*

Yes

No

Have you installed fire or security alarms in your home?*

Yes

No

Have you remodeled or made improvements to your home?*

Yes

No

Do you own professional tools or equipment?*

Yes

No

Do you keep personal property in a self-storage facility?*

Yes

No

Homeowner's insurance policies DO NOT cover certain types of events, including flood, mine subsidence and earthquakes. If you would like information on how to get insurance for such events, please check the boxes:*

Flood

Mine Subsidence

Earthquake

Not Interested

Please explain any changes to your home.

Your Automobiles

Please think back over the last year when answering these questions.

Are you interested in increasing your deductible to lower your premium?*

Yes

No

Do you, or any of your family members, own any autos that are not included in your current auto policy?*

Yes

No

Are any of the autos listed on your policy owned by someone other than you?*

Yes

No

Are any of your autos used for business purposes, including incidental use such as pizza delivery, snow-plowing or ride sharing (Uber, Lyft, etc.)?*

Yes

No

Are you, or any of your family members, furnished an auto for your regular use?*

Yes

No

Do you often rent autos for personal or business use?*

Yes

No

Do you own any trailers?*

Yes

No

If you own a pick up or van, has it been customized?*

Yes

No

Not Applicable

Do any autos contain any equipment that was not factory installed?*

Yes

No

Please explain any changes to your automobiles and "other" vehicles.

Your Miscellaneous Property & Casualty

Please think back over the last year when answering these questions.

Do you own a recreational vehicle (Including camper, ATV, snowmobile, golf cart, etc.)?*

Yes

No

Do you own any watercraft (including jetskis)?*

Yes

No

Do you have a swimming pool?*

Yes

No

Do you have a trampoline?*

Yes

No

Do you have pets?*

Yes

No

Do you ever travel outside the United States for pleasure?*

Yes

No

Do you own any jewelry?*

Yes

No

Do you own furs?*

Yes

No

Do you own silverware, goldware or pewterware?*

Yes

No

Do you own guns?*

Yes

No

Do you own valuable cameras or video equipment?*

Yes

No

Do you own computers?*

Yes

No

Do you own stamp, coin or other valuable collections?*

Yes

No

Do you own antiques, paintings or fine art?*

Yes

No

Do you own valuable musical instruments?*

Yes

No

Please explain any changes.

Your Business Structure

Please think back over the last year when answering these questions.

Have you changed the ownership structure of your business?*

Yes

No

Have you added new or changed your existing operations and/or products?*

Yes

No

Have you begun to buy supplies or sell your products overseas?*

Yes

No

Are you operating out of any new locations or have you closed locations?*

Yes

No

Please explain any changes to your business structure.

Your Personal Liability

Please think back over the last year when answering these questions.

Have you acquired, leased or sold a building, business property and/or equipment?*

Yes

No

Have there been any improvements and/or significant alterations to your building?*

Yes

No

Has your Inventory level changed significantly?*

Yes

No

Have you purchased, leased or sold any Vehicles?*

Yes

No

Please explain any changes to your personal liability.

Your Income Protection

Please think back over the last year when answering these questions.

Have your Businesses revenues changed by more than 10% since last year?*

Yes

No

Do you rely on a single supplier for more than 50% of your materials?*

Yes

No

Do you rely on a single buyer for more than 50% of your sales?*

Yes

No

Please explain any changes to your income protection.

Your Employees & Professional Liability Exposure

Please think back over the last year when answering these questions.

Do you have employees that regularly travel out of state or overseas for business?*

Yes

No

Do any employees use their own personal cars for business purposes?*

Yes

No

Do any Employees work outside your home state or work from their home regularly?*

Yes

No

Do you obtain Certificate of Insurance from all subcontractors, vendors and 1099 workers?*

Yes

No

Are any of the owners a member of any board of directors whether for profit or not?*

About Don Jacobs Insurance Services

We’re an independent insurance agency offering a comprehensive suite of insurance solutions to protect your business and your life from the unexpected.

We don’t just sell insurance. We work closely with clients to help them make important and informed decisions every day when it comes to protection and their future.

Areas served: Don Jacobs Insurance Services is an independent insurance agency offering affordable business insurance, personal insurance, agri-business insurance, life insurance and employee benefits in Central Pennsylvania and surrounding areas. We are also licensed in various other states.

Gift card GIVEAWAY!!! Please leave us a review on our Facebook page and/or Google account to enter! If you leave a review on both pages, you will be entered twice! Winner will be announced July 1st, 2020. Good Luck! ☺

Gift card GIVEAWAY!!! Please leave us a review on our Facebook page and/or Google account to enter! If you leave a review on both pages, you will be entered twice! Winner will be announced July 1st, 2020. Good Luck! ☺